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Pre-Admission Forms

Request for Service



Please fill in all fields below:

MM slash DD slash YYYY
Name
MM slash DD slash YYYY
Address (Physical)
Address (Mailing)
Communication Preference
Appointment Reminder Preference
Referral Source
Primary Language to Recieve Service

Please enter a number from 0 to 12.
(include yourself)
Income Indicator (see "2024 Federal Poverty Guidlines" table)
2024 FEDERAL POVERTY GUIDELINES 200%
FAMILY SIZE GROSS/YR GROSS/MO
1 $30,120 $2,510
2 $40,880 $3,407
3 $51,630 $4,303
4 $62,400 $5,200
5 $73,160 $6,097
6 $83,920 $6,993
7 $94,680 $7,890
8 $105,440 $8,787
Source of Income
Please check any that apply:

If the person named above is not the individual requesting services, please enter you name, relationship and contact phone number:


This field is for validation purposes and should be left unchanged.

General Feelings Questionnaire

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Next Steps: Install the Survey Add-On

This form requires the Gravity Forms Survey Add-On. Important: Delete this tip before you publish the form.

Name(Required)
1. At times I feel like swearing.(Required)
2. I think a lot of people exaggerate their problems to get sympathy.(Required)
3. At times I have periods oflaughing and crying that I can't control.(Required)
4. At times I feel like smashing things.(Required)
5. It takes a lot of arguing to convince people of the truth.(Required)
6. At times I have a strong urge to do something hannful or shocking.(Required)
7. Often I can't understand why I've been so cross or grouchy.(Required)
8. At times my thoughts have raced ahead faster than I speak them.(Required)
9. I have had periods of time where I did things and later, I couldn't remember doing them.(Required)
10. I certainly feel useless at times.(Required)
11. I have never felt better in my life than I do now.(Required)
12. I have had times where I could not control my movements or speech, but I did know what was happening around me.(Required)
13. What others think of me doesn't bother me.(Required)
14. It makes me uncomfortable to put on a stunt at a party, even when other people are doing the same thing.(Required)
15. I have had periods of such restlessness that I couldn't sit still in a chair.(Required)
16. I find it hard to talk to new people the first time.(Required)
17. I am against giving money to beggars.(Required)
18. Once a week, or more often, I become very excited over something.(Required)
19. I frequently find myself worrying about something.(Required)
20. I get mad easily and then get over it soon.(Required)
21. At one or more times in my life, I felt someone was getting me to do something by hypnotizing me.(Required)
22. I am happy just being alone.(Required)
23. It is fun to bet.(Required)
24. I am so touchy about some subjects, I can't talk about them.(Required)
25. The world is full of odd things.(Required)
26. As a child, I occasionally stole things.(Required)
27. I have been afraid of things or people I knew could not hurt me.(Required)
28. I sometimes feel uncomfortable when I am supposed to show happiness over a gift someone got me.(Required)
29. I sometimes get in trouble because I act without thinking.(Required)
30. I am afraid of using a knife or anything very sharp or pointed.(Required)
31. Some of my relatives have done strange things.(Required)
32. I have avoided people I did not want to speak to.(Required)
33. Almost every day something happens to frighten me.(Required)
34. My thoughts are sometimes unusual.(Required)
35. My parents are (or were) too conservative.(Required)

MICHIGAN ALCOHOLISM SCREENING TEST (MAST)


DIRECTIONS: If a statement says something true about you, put a check in the nearby space under YES. If a statement says something not true about you, put a check in nearby space under NO.
PLEASE ANSWER ALL THE QUESTIONS

1. Do you feel you are a normal drinker?(Required)
2. Have you ever awakened the morning after some drinking and found that you could not remember a part of the evening?(Required)
3. Does your wife/husband (or parents) ever worry or complain about your drinking?(Required)
4. Can you stop drinking without a struggle after one or two drinks?(Required)
5. Do you ever feel bad about your drinking?(Required)
6. Do friends or relatives think you are a normal drinker?(Required)
7. Do you ever try to limit your drinking to certain times of the day or to certain places?(Required)
8. Are you always able to stop drinking when you want to?(Required)
9. Have you ever attended a meeting of Alcoholics Anonymous (AA)?(Required)
10. Have you gotten into fights when drinking?(Required)
11. Has drinking ever created problems with you and your wife/husband?(Required)
12. Has your wife/husband (or family member) ever gone to anyone for help about your drinking?(Required)
13. Have you ever lost friends (girlfriend or boyfriend) because of your drinking?(Required)
14. Have you ever gotten into trouble at work because of your drinking?(Required)
15. Have you ever lost a job because of your drinking?(Required)
16. Have you ever neglected your obligations, family or work for two or more days in a row because of your drinking?(Required)
17. Do you ever drink before noon?(Required)
18. Have you ever been told you have liver trouble?(Required)
19. Have you ever had delirium (DT's), severe shaking, heard voices or seen things that were not there after heavy drinking?(Required)
20. Have you ever gone to anyone for help about your drinking?(Required)
22. Have you ever been hospitalized because of your drinking?(Required)
23. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem?(Required)
24. Have you ever been seen at a psychiatric/mental health clinic, or gone to a doctor, social worker, or clergyman for help with an emotional problem in which drinking played a part?(Required)
25. Have you ever been arrested, even for a few hours, because of drunk behavior?(Required)
26. Have you ever been arrested for drunk driving or driving after drinking?(Required)

Drug Use Questionnaire (DAST-20)


The following questions concern your potential involvement with drugs other than alcohol. When you answer the questions, remember that the tenn "drug abuse" does not include alcohol. Instead, it refers to your use of illicit drugs, as well as prescribed or over the counter drugs in excess of the recommended dosage. For example, if you were given a prescription for pain killers, but took more than you were supposed to, that would be included. Remember that the tenn "drug abuse" does not include alcohol. If you have difficulty with a statement, then choose the response that is mostly right.


These questions refer to the last 12 months.

1. Have you used drugs other than those required for medical reasons?(Required)
2. Have you abused prescription drugs?(Required)
3. Do you abuse more than one drug at a time?(Required)
4. Can you get through the week without using drugs?(Required)
5. Are you always able to stop using drugs when you want to?(Required)
6. Have you had "blackouts" or "flashbacks"' as a result of drug use?(Required)
7. Do you ever feel bad or guilty about your drug use?(Required)
8. Does your spouse (or parents) ever complain about your involvement Yes No with drugs?(Required)
9. Has drug abuse created problems between you and your spouse or Yes No your parents?(Required)
10. Have you lost friends because of your use of drugs?(Required)
11. Have you neglected your family because of your use of drugs?(Required)
12. Have you been in trouble at work ( or school) because of drug abuse?(Required)
13. Have you lost your job because of drug abuse?(Required)
14. Have you gotten into fights when under the influence of drugs?(Required)
15. Have you engaged in illegal activities in order to obtain drugs?(Required)
16. Have you been arrested for possession of illegal drugs?(Required)
17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?(Required)
18. Have you had medical problems as a result of your drug use? (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)(Required)
19. Have you gone to anyone for help for a drug problem?(Required)
20. Have you been involved in a treatment program specifically related Yes No to drug use?(Required)

SELF IMAGE
HOW WELL DO YOU LIKE YOURSELF


Mark each answer with a number 1-4 that reflects how you feel about yourself. Using the following statements:
Totally true - 4,
Mostly true - 3,
Partly true - 2,
Hardly true - 1
If the statement is not true at all - 0


WASHINGTON ALCOHOL SCREENING INVENTORY QUESTIONNAIRE


Even if you don’t drink alcohol, please answer all questions.


1. Do you live alone?(Required)
2. Are you employed now?(Required)
3. Do you smoke?(Required)
5. Were you ever arrested?(Required)
6. Are your relatives upset with the way you live?(Required)
7. Is your income sufficient for your basic needs?(Required)
8. Are you bothered by nervousness (irritable, fidgety or tense)?(Required)
9. My judgment is better than it ever was.(Required)
10. Have you recently undergone a great stress (such as something concerning your job, your health, your finances, your family or a loved one)?(Required)
11. I am apt to take disappointments so badly that I can't put them out of my mind.(Required)
12. Have you ever felt the need to cut down on your drinking?(Required)
13. Are you often sad or down in the dumps?(Required)
14. I have had periods in which I carried on activities without knowing later what I had been doing.(Required)
15. Do you have a lot of worries?(Required)
16. I have trouble sleeping.(Required)
17. I am moderate in all my habits.(Required)
18. Have people annoyed you by criticizing your drinking?(Required)
19. I have lived the right kind of life.(Required)
20. My home life is as happy as it should be.(Required)
21. Does drinking help you make friends?(Required)
22. Much of the time I feel as ifl have done something wrong or evil.(Required)
23. Have you ever felt badly or guilty about your drinking?(Required)
24. Do you think that creditors are much too quick to bother you for payments?(Required)
25. I wish I could be as happy as others seem to be.(Required)
26. I sometimes feel that I am about to go to pieces.(Required)
27. Do you usually perspire at night?(Required)
28. I often feel uncomfortable and down in the dumps.(Required)
29. About how many years has it been since your last out-of-town vacation?(Required)
30. I am a high-strung person.(Required)
31. I am satisfied with the way I live.(Required)
32. Have you ever had your driver's license suspended or revoked?(Required)
34. Is there a history of alcoholism in your family?(Required)
35. Do you have a relative who is an excessive drinker?(Required)
36. Are you often depressed or moody?(Required)
37. I often feel as ifl were not myself.(Required)
38. I am often afraid I will not be able to sleep.(Required)
39. Do you often feel afraid to face the future?(Required)
40. Drinking seems to ease personal problems.(Required)
41. How many drinks can you handle and still drive well?(Required)
42. In the last year, how many times have you drunk more than you could handle, but Still been a good driver when you got behind the wheel?(Required)
43. I wish people would stop telling me how to live my life.(Required)
44. I often am afraid without knowing why I am afraid.(Required)
45. At times I think I am no good at all.(Required)
46. Have you ever had a drink first thing in the morning?(Required)
47. A drink or two gives me energy to get started.(Required)
48. Does drinking help you work better?(Required)
49. My daily life is full of things that keep me interested.(Required)
50. My friends are much happier than I am.(Required)
51. I often pity myself.(Required)
52. Would you say that 4 or 5 drinks affect your driving?(Required)
53. I feel tense and anxious most of the time.(Required)
54. Are you often bored and restless?(Required)

Patient Perspective Checklist


I have trouble staying clean and/or sober when...

... when my friends are using around me(Required)
... when I feel lonely(Required)
... when I feel angry(Required)
... when I feel ashamed(Required)
... when I'm in physical pain(Required)
... when I'm in emotional pain(Required)
... when I'm bored(Required)
... when I have an argument with someone(Required)
... when someone is angry or disappointed at me(Required)
... when I just feel like giving up(Required)
... when I want to punish someone important to me(Required)
... when I feel shy around other people(Required)
... when I'm stressed out(Required)
... when I'm not taking good care of mvself(Required)
... when I feel guilty(Required)
... when withdrawal symptoms become too uncomfortable(Required)
... when I see no purpose to my life(Required)
... when I feel that I have never really succeeded at anything(Required)
... when I feel happy(Required)

 

"Thanks to The Center, I was given the hope and skills I needed to not only be clean and sober, but to live a life that's better than I ever thought possible."

You reminded me that there are still people in this world that care. You all made my stay here much easier and more welcoming than I thought it would be. I won't lie, I am a little sad to leave this place. You will always be in my memories and heart.

I feel truly blessed to have come to this particular center!! Thank you to everyone that crossed my path God bless you.

The Center has been delivering quality inpatient and outpatient treatment and counseling for over 45 years.

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